What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION: Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS: We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS: On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS: Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Increasing Engagement of Women Veterans in Health Research.

BACKGROUND: Meaningful engagement of patients in health research has the potential to increase research impact and foster patient trust in healthcare. For the past decade, the Veterans Health Administration (VA) has invested in increasing Veteran engagement in research. OBJECTIVE: We sought the perspectives of women Veterans, VA women's health primary care providers (WH-PCPs), and administrators on barriers to and facilitators of health research engagement among women Veterans, the fastest growing subgroup of VA users. DESIGN: Semi-structured qualitative telephone interviews were conducted from October 2016 to April 2018. PARTICIPANTS: Women Veterans (N=31), WH-PCPs (N=22), and administrators (N=6) were enrolled across five VA Women's Health Practice-Based Research Network sites. APPROACH: Interviews were audio-recorded and transcribed. Consensus-based coding was conducted by two expert analysts. KEY RESULTS: All participants endorsed the importance of increasing patient engagement in women's health research. Women Veterans expressed altruistic motives as a personal determinant for research engagement, and interest in driving women's health research forward as a stakeholder or research partner. Challenges to engagement included lack of awareness about opportunities, distrust of research, competing priorities, and confidentiality concerns. Suggestions to increase engagement include utilizing VA's patient-facing portals of the electronic health record for outreach, facilitating "warm hand-offs" between researchers and clinic staff, developing an accessible research registry, and communicating the potential research impact for Veterans. CONCLUSIONS: Participants expressed support for increasing women Veterans' engagement in women's health research and identified feasible ways to foster and implement engagement of women Veterans. Given the unique healthcare needs of women Veterans, engaging them in research could translate to improved care, especially for future generations. Knowledge about how to improve women Veterans' research engagement can inform future VA policy and practice for more meaningful interventions and infrastructure.

Expert Recommendations for Designing Reporting Systems to Address Patient-Perpetrated Sexual Harassment in Healthcare Settings.

BACKGROUND: Patient-perpetrated sexual harassment toward staff and patients is prevalent in Veterans Affairs and other healthcare settings. However, many healthcare facilities do not have adequate systems for reporting patient-perpetrated harassment, and there is limited evidence to guide administrators in developing them. OBJECTIVE: To identify expert recommendations for designing effective systems for reporting patient-perpetrated sexual harassment of staff and patients in Veterans Affairs and other healthcare settings. DESIGN: We conducted qualitative interviews with subject matter experts in sexual harassment prevention and intervention during 2019. PARTICIPANTS: We used snowball sampling to recruit subject matter experts. Participants included researchers, clinicians, and administrators from Veterans Affairs/other healthcare, academic, military, and non-profit settings (n = 33). APPROACH: We interviewed participants via telephone using a semi-structured guide and analyzed interview data using a constant comparative approach. KEY RESULTS: Expert recommendations for designing reporting systems to address patient-perpetrated sexual harassment focused on fostering trust, encouraging reporting, and deterring harassment. Recommendations included the following: (1) promote a climate in which harassment is not tolerated; (2) take proportional, corrective actions in response to reports; (3) minimize adverse outcomes for reporting parties; (4) facilitate and simplify reporting processes; and (5) hold the reporting system accountable. Specific strategies related to each recommendation were also identified. CONCLUSIONS: This qualitative study generated initial recommendations to guide healthcare administrators and policy makers in assessing, developing, and improving systems for reporting patient-perpetrated sexual harassment toward staff and other patients. Results indicate that proactive, careful design and ongoing evaluation are essential for ensuring that reporting systems have their intended effects and mitigating the risks of inadequate systems. Additional research is needed to evaluate strategies that effectively address patient-perpetrated harassment while balancing patients' clinical needs.

Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings.

INTRODUCTION: One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training-teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event-is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings. METHODS: We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method. RESULTS: Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context. CONCLUSIONS: Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation.

Women Veterans' Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign.

PURPOSE: In 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans' experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation). METHODS: We administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ2 analyses, adjusting for facility-level clustering. RESULTS: There were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05). CONCLUSIONS: One year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.

Promoting learning health system feedback loops: Experience with a VA practice-based research network card study.

BACKGROUND: We tested the capacity of the 60-site VA Women's Health Practice-Based Research Network (WH-PBRN), embedded within VA, to employ a multisite card study to collect women Veterans' perspectives about Complementary and Integrative Health (CIH) and to rapidly return findings to participating sites and partnered national policy-makers in support of a Learning Health System (LHS) wherein evidence generation informs ongoing improvement. METHODS: VA primary care clinic clerks and nurses distributed anonymous surveys (patient feedback forms) at clinics for up to two weeks in fiscal year 2017, asking about CIH behavior and preferred delivery methods. We examined the project's feasibility, representativeness, acceptability, and impact via a tracking system, national administrative data, debriefing notes, and three surveys of WH-PBRN Site Leads. RESULTS: Twenty geographically diverse and largely representative VA Medical Centers and 11 Community-Based Outpatient Clinics volunteered to participate. Over six months, N = 1191 women Veterans responded (median 57; range 8-151 per site). In under three months, we returned local findings benchmarked against multisite findings to all participating sites and summary findings to national VA partners. Sites and partners disseminated results to clinical and leadership stakeholders, who then applied results as warranted. CONCLUSIONS: VA effectively mobilized an embedded PBRN to implement a timely, representative, acceptable and impactful operations project. IMPLICATIONS: Card studies by PBRNs within large, national healthcare systems can provide rapid feedback to participating sites and national leaders to guide policies, programs, and practices. LEVEL OF EVIDENCE: Self-selected respondents could have biased results.

Challenges to Addressing Patient-Perpetrated Sexual Harassment in Veterans Affairs Healthcare Settings.

BACKGROUND: Patient-perpetrated sexual harassment adversely affects healthcare organizations, staff, and other patients, yet few institutions have clear policies to address it. Understanding the challenges to addressing patient-perpetrated harassment can inform development of institutional guidelines and interventions. OBJECTIVE: To identify challenges and stakeholder-driven recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at Veterans Health Administration (VA) facilities. DESIGN: We conducted qualitative interviews with 24 staff, clinicians, and administrators across four VA healthcare facilities. PARTICIPANTS: We used snowball sampling to identify stakeholders with expertise in overseeing care environments, providing care to women patients, and/or managing disruptive patient behavior. APPROACH: We interviewed participants in-person or via phone using a semi-structured guide. Two members of the research team analyzed the interview data using the constant comparative method. KEY RESULTS: Participants identified challenges to addressing patient-perpetrated harassment of women staff and patients that were interrelated and spanned multiple levels. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. At the staff level, perceived challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Finally, participants identified patient-level challenges, including patient characteristics such as age, cognitive impairment, and psychiatric diagnoses that complicated assessments of intentionality and culpability. Participant recommendations focused on development and implementation of policies, reporting systems, public norms campaigns, staff and patient education, and bystander intervention training. CONCLUSIONS: VA offers unique opportunities for studying patient-perpetrated harassment of women staff and patients due to its majority-male patient population, culture informed by military gender norms, and commitment to reducing harassment at its facilities. Our findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multilevel interventions.

Mobilizing embedded research and operations partnerships to address harassment of women Veterans at VA medical facilities.

Key insights: A: Addressing a complex problem like harassment in VA medical facilities requires committed, engaged collaboration at multiple levels of the organization. B: Timely feedback of initial research findings to operations partners enabled rapid and more responsive development of new programs and policies. C: Our research-clinical partnership has enabled us to pursue targeted change from the outset, while incorporating real-time findings from embedded researchers working to develop a comprehensive understanding of the problem.

Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration.

PURPOSE: One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS: Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS: At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS: We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.

Women Veterans' Perspectives on How to Make Veterans Affairs Healthcare Settings More Welcoming to Women.

PURPOSE: Women veterans are a rapidly increasing subset of the Veterans Affairs (VA) patient population but remain a numerical minority. Men veteran-dominated health care settings pose unique considerations for providing care to women veterans in a comfortable and welcoming environment. We analyzed patient suggestions on how to make the VA more welcoming to women. METHODS: We surveyed a convenience sample of women veteran patients who visited 1 of 26 VA locations in August and September of 2017. Women veterans were invited to complete brief anonymous questionnaires that included questions about harassment experiences and feeling welcome at the VA, and an open-ended question about suggestions to make the VA more welcoming to women. We analyzed data from the open-ended question using the constant comparison method. RESULTS: Among respondents (N = 1,303), 85% felt welcome at the VA. Overall, 29% answered the open-ended prompt for a total of 490 distinct responses: 260 comments and 230 suggestions. Comments included praise for the VA (67%) and stories about feeling uncomfortable or harassed in the VA (26%). Suggestions included those related to VA staff (31%), the environment of care (18%), additional resources for women veterans (18%), clinical services for women veterans (15%), changing men veterans' behavior toward women veterans at the VA (5%), and making the treatment of women and men the same (5%). CONCLUSIONS: Although most women veterans felt welcome in the VA, patient-centered suggestions offer opportunities for making the VA more welcoming to women. Soliciting patient suggestions and increasing awareness of how feeling welcome is experienced by patients are first steps to health care settings becoming more inclusive.

Usual Care Among Providers Treating Women Veterans: Managing Complexity and Multimorbidity in the Era of Evidence-Based Practice.

To better understand VA providers' approaches to and perspectives on providing care to women Veterans, providers (n = 97) in primary care and mental health settings were interviewed about women's perceived treatment needs, types of care provided, and perceptions of evidence-based treatments (EBTs) for this population. Providers perceived that women Veteran VA users are often diagnostically complex and require a coordinated approach to treatment planning. They struggled with decisions about how to offer services such as EBTs and collaborative care in light of comorbidity and psychosocial stressors, and endorsed the belief that a tailored approach and consideration of these factors is essential in providing care.

Evidence Map: Reporting of Results by Sex or Gender in Randomized, Controlled Trials with Women Veteran Participants (2008 to 2018).

BACKGROUND: Higher participation of women in randomized, controlled trials (RCTs) has not led to significantly improved reporting of sex-stratified results. A recent evidence map of research on women veterans revealed that many studies did not report results by sex or gender. This study's objectives were to compare characteristics of RCTs with women veteran participants that did or did not report results by sex or gender and to assess how sex and gender are addressed in research with women veterans. METHODS: We extended the prior evidence map with a systematic search for RCTs with women veterans, published between 2008 and 2018. We compared the characteristics of RCTs that reported results by sex or gender with those of RCTs that did not, and reviewed methodology and reporting of sex/gender analyses. RESULTS: In addition to 11 studies from the prior evidence map, we assessed 1,820 abstracts for relevance and ultimately included 45 unique RCTs. Five trials included only women and 40 included both men and women (median, 14.3% women). Ten studies reported results by sex or gender. These trials were larger (median study size of n = 343.5 vs. n = 125.5) and included a higher median proportion of women participants (16.8% vs. 11.2%) than studies without sex/gender results. Ten of 11 trials that tested pharmacologic or device interventions did not report results by sex or gender. CONCLUSIONS: Reporting of results by sex or gender remains low in veteran research, but may improve with larger studies and increased recruitment of women veterans into trials. Trials of pharmacologic or device interventions may be targets for future reporting requirements. Standardization could improve attention to sex and gender in methodology and reporting.

Gender Differences in Veterans' Perceptions of Harassment on Veterans Health Administration Grounds.

PURPOSE: Stranger harassment at Veterans Health Administration (VA) facilities is prevalent, affecting one in four women veteran VA primary care users. Harassment interferes with health care quality and may result in veterans forgoing or delaying needed care. To better understand this phenomenon, gender-stratified discussion groups were held with men and women veterans. This article examines gender differences in veterans' perceptions and experiences of harassment on VA grounds. METHODS: We conducted a total of 15 discussion groups at four VA medical centers, eight with men (n = 57) and seven with women (n = 38). Transcripts were coded using the constant comparative method and analyzed for overarching themes. RESULTS: Awareness of harassment was not uniformly high among participants. Although women voiced clear understandings and experiences of specific behaviors constituting harassment (e.g., cat-calls, sexual comments), many men expressed confusion about how to differentiate between harassment, "harmless flirting," and general friendliness; they were unsure which behaviors "cross a line." Furthermore, men placed the onus on women for setting boundaries, whereas women indicated it was not their responsibility to "train" men about acceptable behavior. Men and women agreed that VA staff hold primary responsibility for preventing and managing harassment. CONCLUSIONS: Substantive gender differences in understandings of harassment exist among veteran VA users. To minimize harassment, veterans recommend education of men veteran VA users, and staff-oriented trainings. Privacy, safety, dignity, and security are the cornerstones of women veterans' health care, per VA policy. Harassment undermines these standards, impeding women's access to VA care and compromising both their health outcomes and health care experiences. Understanding harassment through a gendered lens is a critical step in designing comprehensive initiatives that respond to diverse viewpoints and experiences.

Prevalence of Stranger Harassment of Women Veterans at Veterans Affairs Medical Centers and Impacts on Delayed and Missed Care.

BACKGROUND: Harassment of servicewomen during military service has been well-documented, but harassment of women veterans in Veterans Affairs (VA) health care settings has not been studied systematically. We assessed the prevalence and impacts of harassment among women veterans who use VA health care. METHODS: From January to March 2015, we conducted computer-assisted telephone interviews of randomly sampled women veterans with three or more primary care and/or women's health visits at 1 of 12 VA medical centers. We asked if patients had experienced inappropriate/unwanted comments or behavior from male veterans at VA in the past year. We measured sociodemographics, health status, perceptions of VA care, delayed/unmet health care need, and care preferences. All analyses were weighted to account for the disproportionate sample design and nonresponse. Brief, open-ended descriptions of harassment were transcribed and coded. RESULTS: Approximately one in four women veterans (25.2%; n = 1,395, response rate 45%) reported inappropriate/unwanted comments or behavior by male veterans on VA grounds. Site prevalence ranged from 10% to 42%. Incident descriptions were wide-ranging (e.g., catcalls, sexual/derogatory remarks, propositioning, stalking, and denigration of veteran status). Reports of harassment were more common among women with histories of military sexual trauma; other trauma exposures (e.g., combat, childhood); positive screens for anxiety, depression, and/or posttraumatic stress disorder; and fair/poor health. Those who reported harassment were significantly less likely to report feeling welcome at VA, and more likely to report not feeling safe, and delaying/missing care. CONCLUSIONS: One-quarter of women veteran VA users experienced harassment in VA health care settings; these experiences negatively impacted women's health care experiences and use.

Experiences in the Veterans Health Administration and Impact on Healthcare Utilization: Comparisons Between LGBT and Non-LGBT Women Veterans.

PURPOSE: This study aimed to compare experiences related to healthcare of LGBT women and non-LGBT women in a sample of routine users of Veterans Health Administration (VHA) primary care services and examine the impact of those experiences on delaying or missing appointments for VHA care. METHODS: Women veterans (N = 1391) who had at least three primary care visits in the previous year at 12 VHA facilities were surveyed by phone in January-March 2015 in a baseline wave of a cluster-randomized quality improvement trial. The majority identified as non-LGBT (1201; 85.6%) with 190 (14.4%) women identified as LGBT, based on items measuring sexual orientation and gender identity. RESULTS: In models controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women veterans experiencing harassment from male veterans at VHA in the past 12 months, as well as feeling unwelcome or unsafe at their VHA. Compared with non-LGBT women veterans, LGBT women veterans attributed missing needed care more often in the previous 12 months to concerns about interacting with other veterans. Participant descriptions of harassment indicated that male veterans' comments and actions were distressing and influenced LGBT women's healthcare accessing behavior. CONCLUSIONS: Compared with non-LGBT women, LGBT women were more likely to report harassment and feeling unwelcome at VHA. Some LGBT women reported delaying or missing needed care, primarily due to concerns about interacting with other veterans. Additional work is necessary to help LGBT women veterans feel safe and welcome at VHA facilities and, thereby, reduce barriers to LGBT women veterans accessing needed care.

Practice-based research networks add value to evidence-based quality improvement.

Background: Evidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value. METHODS: We conducted a four-site cluster randomized trial of an EBQI approach to tailoring an evidence-based gender awareness curriculum in the VA Women's Health PBRN (WH-PBRN). After curriculum implementation, site teams identified impacts of the WH-PBRN context on EBQI processes using qualitative methods, including a formal review of project call minutes, post-project debriefing calls, and structured site team input. WH-PBRN site feedback was mapped to the Replicating Effective Programs implementation phases: pre-condition, pre-implementation, implementation, and maintenance/evolution. RESULTS: The pre-condition phase benefited from the existing WH-PBRN research-clinician relationships to facilitate stakeholder engagement and build project buy-in at local sites. During pre-implementation, differences across WH-PBRN sites offered variations in local tailoring of EBQI elements. The WH-PBRN Coordinating Center helped resolve process complexities stemming from local resource differences and the sharing of mid-project adaptations during implementation. Local efforts were amplified in the maintenance phase by WH-PBRN dissemination of findings. Conclusions: The PBRN strengthened multi-site EBQI activities across all implementation phases. Implications: PBRNs contribute to the uptake of evidence into everyday practice, and may serve as an important component of the future implementation of evidence-based initiatives. Level of evidence: V.

Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain.

Systematic reviews (SRs) have the potential to contribute uniquely to the evaluation of sex and gender differences (termed "sex effects"). This article describes the reporting of sex effects by SRs on interventions for depression, type 2 diabetes mellitus, and chronic pain conditions (chronic low back pain, knee osteoarthritis, and fibromyalgia). It includes SRs published since 1 October 2009 that evaluate medications, behavioral interventions, exercise, quality improvement, and some condition-specific treatments. The reporting of sex effects by primary randomized, controlled trials is also examined. Of 313 eligible SRs (86 for depression, 159 for type 2 diabetes mellitus, and 68 for chronic pain), few (n = 29) reported sex effects. Most SRs reporting sex effects used metaregression, whereas 9 SRs used subgroup analysis or individual-patient data meta-analysis. The proportion of SRs reporting the sex distribution of primary studies varied from a low of 31% (n = 8) for low back pain to a high of 68% (n = 23) for fibromyalgia. Primary randomized, controlled trials also infrequently reported sex effects, and most lacked an adequate sample size to examine them. Therefore, all SRs should report the proportion of women enrolled in primary studies and evaluate sex effects using appropriate methods whenever power is adequate.

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression.

BACKGROUND: Whereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed. PURPOSE: This study tests whether stigma, defined as depression label avoidance, predicted patients' preferences for depression treatment providers, patients' prospective engagement in depression care, and care quality. METHODS: We conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression. RESULTS: Relative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care. CONCLUSIONS: High stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.